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    <title>Getting information</title>
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    <div class="container">

      <div class="masthead">
          <div style="float: right;">Logged in as: <a href="#" id="name">Meskerem Asfaw</a></div>
        <h3 class="muted">Personal health assessment questionnaire</h3>
        <br />
      </div>
	
        <div class="progress">
            <div class="progress-bar" role="progressbar" aria-valuenow="60" aria-valuemin="0" aria-valuemax="100" id="progbar" style="width: 0%;">
                <span id="bar">0% Complete</span>
            </div>
        </div>
			  
	<div class="well" id="diseases">
		<legend>Do you have or had any of the following diseases:</legend>
                <table border="0" width ="100%" class="table table-striped">
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Chest pain, myocardial infarction, irregular pulse, heavy breathing triggered by effort.">1. Heart disease</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="1no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="1yes"><button class="btn btn-default" id="1yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="1yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type and year here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            2. High blood pressure
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="2no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" id="2yes-btn" type="button">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Blood clots, haemophilia, easy bruising / nose bleeding.">3. Bleeding disorders</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="3no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="3yes"><button class="btn btn-default" id="3yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="3yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Stroke, ischemia, brain haemorrhage, epilepsy.">4. Neurological disease</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="4no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="4yes"><button class="btn btn-default" id="4yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="4yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type and year here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Asthma, COPD (Chronic Obstructive Pulmonary Disease), snoring with apnoea.">5. Pulmonary or respiratory diseases</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="5no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="5yes"><button class="btn btn-default" type="button" id="5yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="5yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Broadly controlled, insulin, treated by medication.">6. Diabetes</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="6no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="6yes"><button class="btn btn-default" type="button" id="6yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="6yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            7. Thyroid disease
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="7no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="7yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            8. Kidney disease
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="8no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="8yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            9. Liver disease
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="9no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="9yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Peptic ulcer, heartburn, acid reflux, oesophageal hernia.">10. Stomach problems</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="10no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="10yes"><button class="btn btn-default" type="button" id="10yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="10yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Hepatitis, HIV, tuberculosis or other serious infectious diseases.">11. Infectious diseases</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="11no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="11yes"><button class="btn btn-default" type="button" id="11yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="11yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            12. Psychological problems that the hospital should know
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="12no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="12yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Impaired mobility or neck instability.">13. Rheumatic disease</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="13no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="13yes"><button class="btn btn-default" type="button" id="13yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="13yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            14. Mobility limitations
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="14no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="14yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            15. Other diseases / conditions
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="15no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="15yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                </table>
        </div>
        <div class="well" id="previous">
        <legend>Previous surgeries:</legend>                
                <table border="0" width ="100%" class="table table-striped">
                    <tr>
                        <td width="30%">
                            Have you had surgery before?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="16no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="16yes"><button class="btn btn-default" id="16yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="16yes" class="form-control" disabled="disabled" placeholder="If yes, for what? In which year? Were there complications?">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            Have you had general or spinal anaesthesia before?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="17no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="17yes"><button class="btn btn-default" id="17yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="17yes" class="form-control" disabled="disabled" placeholder="If yes, did you have abnormal reaction to the anaesthetic / anaesthesia?">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                </table>
        </div>
        <div class="well" id="general">
                <legend>General information:</legend>
                <table border="0" width ="100%" class="table table-striped">
                    <tr>
                        <td width="30%">
                            <a href="#" data-toggle="popover" data-placement="right" id="basic-popover" title="Example:" data-content="Sulfa, penicillin, latex, acetylsalicylic acid (aspirin), peanuts, soy, local anaesthesia.">1. Do you have allergies?</a>
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="18no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="18yes"><button class="btn btn-default" id="18yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="18yes" class="form-control" disabled="disabled" placeholder="If yes, please specify type here...">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            2. Are you easily nausea / motion sick?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="19no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" id="19yes-btn" type="button">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            3. Do you have loose teeth?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="20no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="20yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            4. Do you have decreased jaw mobility?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="21no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <button class="btn btn-default" type="button" id="21yes-btn">Yes</button>
                                </span>
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            5. Do you smoke?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="22no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                    <label for="22yes"><button class="btn btn-default" type="button" id="22yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="22yes" class="form-control" disabled="disabled" placeholder="If yes, please specify the number of cigarettes / day:">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            6. Have you smoked before?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="23no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="23yes"><button class="btn btn-default" type="button" id="23yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="23yes" class="form-control" disabled="disabled" placeholder="If yes, end date / year:">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            7. Do you need an interpreter?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                      <button class="btn btn-default" id="24no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="24yes"><button class="btn btn-default" type="button" id="24yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="24yes" class="form-control" disabled="disabled" placeholder="If yes, what language?">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            8. Have you received hospital treatment abroad in the last 6 months?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="25no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="25yes"><button class="btn btn-default" type="button" id="25yes-btn">Yes</button></label>
                                </span>
                                  <input type="text" id="25yes" class="form-control" disabled="disabled" placeholder="If yes, specify which:">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                </table>
	</div>
        <div class="well" id="women">
		<legend>For women:</legend>                
                <table border="0" width ="100%" class="table table-striped">
                    <tr>
                        <td width="30%">
                            Have you given birth?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="26no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="26yes"><button class="btn btn-default" id="26yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="26yes" class="form-control" disabled="disabled" placeholder="If yes, how many times? Year? How many caesarena?">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                    <tr>
                        <td width="30%">
                            Are you breastfeeding or are you pregnant?
                        </td>
                        <td width="8%">
                                <div class="input-group">
                                  <span class="input-group-btn">
                                    <button class="btn btn-default" id="27no-btn" type="button">No</button>
                                  </span>
                                </div><!-- /input-group -->
                        </td>
                        <td width="10%"></td>
                        <td>
                              <div class="input-group">
                                <span class="input-group-btn">
                                  <label for="27yes"><button class="btn btn-default" id="27yes-btn" type="button">Yes</button></label>
                                </span>
                                  <input type="text" id="27yes" class="form-control" disabled="disabled" placeholder="If yes, please specify.">
                              </div><!-- /input-group -->
                        </td>
                    </tr>
                </table>
        </div>
        <div class="well" id="other">
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                        <td>
                            <input type="text" class="form-control" placeholder="Amount (number per day)">
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                        <td>
                            <input type="text" class="form-control" placeholder="Name of the medicine">
                        </td>
                        <td>
                            <input type="text" class="form-control" placeholder="Dosage (mg)">
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                        <td>
                            <input type="text" class="form-control" placeholder="Amount (number per day)">
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